Maternal participation in a nutrition education program in Uganda is associated with improved infant and young child feeding practices and feeding knowledge: a post-program comparison study

Study design

We conducted a cross sectional study to compare dietary adequacy and caregiver feeding knowledge among caregiver-child dyads who participated in the BBB program and those that did not. We administered a household nutrition knowledge survey and 24-h dietary recalls among children who had completed the BBB program between January and July 2009, and a matched community comparison group.

Setting

Bundibugyo is one of four districts in Uganda’s western region. At the time of the study, it was the only western district with no paved roads or electricity. The district is geographically isolated from Uganda due to its western border with the Democratic Republic of Congo, and eastern boundary with the Rwenzori mountains. The majority of families rely on subsistence farming, with a small export market for coffee and cocoa. Most cooking is done over open fire or with charcoal in metal grills.

The Bakonjo and Babwisi are the two predominant people groups in the 290,000-person district, which includes 52,500 (18%) children under 5 years. The prevalence of stunting (Height-for-age Z score (HAZ) < − 2) is 44%, compared to the national prevalence of 33% [13]. IYCF practices in Uganda present a major modifiable risk factor for reducing undernutrition and morbidity in children. Among children under 6 months, only 63% are exclusively breastfed. Among children 6 to 23 months, only 12.8% of children are fed 4 or more food groups per day, and just 5.8% are fed a minimally acceptable diet, which encompasses dietary diversity, feeding frequency, and being breastfed or fed milk products. Uganda woman face numerous challenges to their freedom to make decisions: nearly 40% of currently married women report that their husbands make the primary decisions about women’s health care and household purchases [13]. Constrained decision-making among women has been described to limit women’s caregiving capabilities for nutrition [14].

Study tools

Based on previous qualitative interviews, we developed a quantitative survey and dietary recall instrument to assess caregivers’ nutrition knowledge and children’s diet quality [14]. Post-program (PP) caregivers were asked to recall key messages or topics that they received from the BBB program. Comparison Group (CG) caregivers were asked to recall any nutritional education messages they had ever received about child nutrition or feeding. Caregiver responses were coded in a table that listed pre-written IYCF messages, developed from UNICEF guidelines and the BBB curriculum [15]. Space was provided for answers outside of these pre-determined messages, and new categories were created to accommodate these responses.

Children’s diet adequacy was assessed through 24-h dietary recalls, and was obtained for each participating child immediately following the caregiver survey by study personnel trained in diet assessment methods. Two dietary recalls per child were collected on non-consecutive days in order to estimate the usual diet of children. The name and time of each meal and the ingredients and method of preparation for each food item were obtained in each recall. Next, the portion size offered and amount consumed by the child of interest were estimated using standard local utensils (e.g. tablespoon, 800 ml plate, 500 ml cup). Cups and plates were marked with fraction lines to assist caregivers in estimating portion sizes. Child ages were calculated by subtracting the birth date provided from a child health card, or from caregiver report when this was unavailable. Child weights were obtained through use of a hanging scale with a net for infants ≤12 months, or weighing pants for children >12 months.

Assessment of infant and young child feeding (IYCF) practices

Among a subset of children ages 6 to 23 months, we used 24-h recall data to construct World Health Organization indicators for IYCF: continued breastfeeding at 12 months, feeding iron-rich complementary foods, minimum feeding frequency, minimum dietary diversity, and minimally acceptable diet [16]. Minimum meal frequency is defined as being fed solid or semi-solid foods the minimum number of times per day based on a child’s age. For breastfed children, this is twice for 6–8 months, three times for 9 to 23 months; non-breastfed children should be fed four or more times per day. Minimum dietary diversity is defined as being fed 4 or more food groups per day. A minimally acceptable diet is met for breastfed children if they were fed three or more food groups and were fed the age-specific minimum number of times per day (≥2 for children 6–8 months ≥ 3 for children ages 9–23 months). Non-breastfed children are required to consume a minimum of four food groups, consume milk or milk-based products, and be fed a minimum of four times per day. A food group was counted if a child consumed at least 1 g of a food item from any of the following seven groups: 1) infant formula, milk other than breast milk, cheese or yogurt, or other milk products; 2) foods made from grains, roots, and tubers, including matoke, porridge, fortified baby food from grains; 3) vitamin A-rich fruits and vegetables; 4) other fruits and vegetables; 5) eggs, meat, poultry, fish, shellfish and organ meats; 6) legumes and nuts; and 7) foods made with oil, fat, or butter [16]. Since we obtained two dietary recall observations per child, we indicated that an indicator was met if met on both days of recall. While this is a higher requirement than used in Demographic and Health Survey (DHS) assessments, we required that children meet the indicators on both days to assess usual diets more accurately.

Study population

The study recruitment process is summarized in Fig. 1. PP caregivers were randomly selected from the list of program beneficiaries who were enrolled in the BBB program from different villages in the three sub-counties of Ndugutu, Bubandi, and Busaru between January and July 2009. We identified caregivers at their homes using program registries and recruited mothers to participate in a survey about their knowledge about child feeding and to measure their children’s diets on two days. All PP caregivers who participated in the 10-week BBB Program between January to July 2009 were eligible for recruitment. All study participants were recruited for the post-program study between August and October 2009. All PP caregivers were recruited four to eight weeks after program participation, one to two months after LNS supplements and education were discontinued. Per normal protocol, all caregiver contact with the program was discontinued after 10 weeks of participation; children who fail to make improvements in growth were referred to the health center for examination by physician and potentially in-patient treatment. Research teams contacted the local chairperson in each village to explain the study purpose, share the human subject’s approval, and to obtain additional approval from these local leaders to speak with caregivers in their jurisdiction. All surveys and dietary recalls were conducted in either Lubwisi or Lukonjo, the two primary local languages, depending on the caregiver preference. All caregivers of children in the CG, and 50 caregivers of PP children completed the child feeding survey, for a total of 111 survey respondents. Eleven of the 61 PP participants were unavailable for the child feeding survey. There were no identifiable differences between respondents and non-respondents for the child feeding survey.

Comparison group

We recruited a post-test only comparison group (CG) from the same source population (villages) that produced the PP group to compare dietary adequacy and caregiver feeding knowledge [17]. Since PP children had recently participated in a 10-week program designed for children who were underweight, and which sought to enroll most of the underweight children in their communities, we elected to instead match children based on age and village of residence. We obtained a list of households with children of similar ages (±2 months) to the PP children from the local chairpersons in each village. CG caregivers were then randomly sampled from this list with one-week lag to the PP group. This method enabled the PP and CG groups to be similar in age and broader socio-economic characteristics that are largely homogenous within villages. This study design assumes that secular trends in infant feeding knowledge or practice would have been trivial in one to three months of time, and that there was minimal spillover from program messages from the program group to the broader community.

All interviews were conducted in participant homes and lasted approximately 30 min. No eligible participants who could be located refused participation. Per study protocol, the informed consent process was administered orally and with a two-page form. Written consent was obtained from subjects who could write their names. Mothers who could not write their names wrote an “X” to indicate written consent.

Program components of the BBB supplemental feeding program

The BBB program operated in two health centers in the Bundibugyo District and enrolls 50 children and their caregivers per 10-week cycle. The program delivered complementary feeding education to caregivers and 650 kcal/day (128 g/day) of a peanut and soy-based LNS to supplement the diets of underweight children (WAZ < −2). For children ages 12–36 months, the daily ration provided the full estimated average requirement (EAR) for vitamins A, folate, and zinc, and approximately 50% for calcium and vitamin C [11]. Previous evaluation of a different cohort of program participants indicated that the food supplements were well-received and incorporated into the normal child feeding routine [18].

At each weekly visit caregivers received child growth monitoring, nutrition education, and the LNS. Village health workers and health center staff delivered the education, which was based on UNICEF IYCF guidance. The program emphasized 1) the impact of early nutrition on school performance later in life, 2) antenatal nutrition, 3) growth monitoring and promotion, 4) exclusive breastfeeding through 6 months and continued breastfeeding on demand after 6 months; 5) introduction of complementary foods at 6 months; 6) feeding a diverse diet that includes animal source foods; complementary feeding practices, 7) using an attentive, responsive child feeding style, 8) feeding children during and after illness, and 9) appropriate hygiene and sanitation practices [12, 15].

Hypothesis and statistical analysis

IYCF indicators, practices, and caregiver knowledge of child feeding practices were compared using two-sample proportion and mean comparison tests (two-tailed) using STATA version 14.0 [19]. We hypothesized that a greater proportion of PP children would meet the recommended IYCF indicators, and that the proportion of mothers who recalled specific healthful child feeding practices would be greater in the PP group compared to the CG group. Group proportion differences controlled for underweight status, presence of the father in the home, maternal education, primary means of food acquisition, type of material used to construct the respondent’s home. These confounders were selected because they were potentially associated with the exposure (group membership), independent risk factors for the outcome (IYCF practices and knowledge), do not lie in the causal path between the exposure and the outcome, and could not be a result of the outcome. The sample size was calculated based on the assumptions of α = 0.05, β = 80%, and a two-tailed test in order to detect a 20% difference in the proportion of children who were fed a minimally acceptable diet. Based on these parameters, a total sample of 118 was required, with 59 children per study group.

Ethical approval

This study was conducted according to the guidelines established in the Declaration of Helsinki. Per study protocol, the informed consent process was administered orally and with a two-page form. Written consent was obtained from subjects who could write their names. Mothers who could not write their names wrote an “X” to indicate written consent. All procedures involving human subjects are approved by the University of North Carolina School of Public Health Institutional Review Board, # 08–1100 and the Bundibugyo District Health Office, which provided local ethical approval of the study.